Transfer/Rollover/Exchange Form

Use this form to:

move retirement plan assets into a Fidelity account within your current employers retirement plan consolidate multiple retirement accounts that are all at Fidelity but are currently with different employers move IRA assets into a Fidelity account within your current employers retirement plan

Before You Begin STOP! Before completing this form, please confirm that your retirement plan allows the Transfer/Rollover/Exchange form to be used for rollovers and exchanges. Many retirement plans require that their own forms be used. Please contact your benefits office, or call Fidelity at the toll free number before you submit this form to Fidelity. Submission of an incorrect form will delay the processing of rollover or exchange.
All information on this form is required Additional paperwork may be required as well. If you do not provide all information and all necessary signatures your request will be delayed. If a prior employer sends a rollover check directly to you, forward the check to Fidelity for processing.
Make sure your current plan can accept assets from the plan where your money is now No employer-sponsored plan on this form can accept assets from a Roth IRA or Coverdell IRA. Some plans CANNOT accept assets from certain other types of plans. Check with Fidelity to be sure.

If you dont currently have an employee retirement account at Fidelity, you will need to open one You can get the materials for this at www.fidelity.com/atwork. If your current employer does not offer a retirement plan for which Fidelity handles the recordkeeping, such a plan must be set up before you can use this form. Moving assets to or from a 457(b) plan sponsored by a tax-exempt employer requires a different form If you are moving assets into or out of a 457(b) plan that is sponsored by a tax-exempt employer (and not a government employer), contact Fidelity.
Print clearly in black ink.

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1. Participant
First Name Middle Initial Last Name

U.S. Mailing Address

City

State

Zip/Postal Code

Daytime Phone

Evening Phone

Social Security or Tax ID No.

Employer Sponsoring Fidelity Account (as it appears on account statement or enrollment material)

Employer City

Employer State

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020770002

2. Investment Provider You Are Moving Assets From

Provider Name

Examples: VALIC, Vanguard, TIAA-CREF, Lincoln, ING

Provider Mailing Address

City

State

Zip/Postal Code

Provider Phone Number

Extension

How many assets from this provider do you want to move to Fidelity?

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3.1 #1 Asset To Move To Fidelity

A. ACCOUNT NUMBER AND TYPE You can get your account number from

your most recent statement or the investment provider. If you do not provide a valid number, we will use your Social Security or Tax ID number to identify assets to be moved.
Account type 401(a) or 401(k) 403(b)

Account/Contract Number

457(b) governmental

IRA
Must be a Traditional, Rollover, or SEP IRA, or a SIMPLE IRA that is at least 2 years old.

B. AMOUNT YOU WANT TO MOVE Move all assets to Fidelity (full liquidation)

Select only one.

Move only this percentage of assets (partial liquidation): Move only this dollar amount of assets (partial liquidation):

C. TYPE OF TRANSACTION Select the description that most accurately reflects the transaction you are requesting. The description you select will determine whether your transaction is considered a transfer, a rollover, or an exchange. Each of these is slightly different for recordkeeping and tax reporting purposes. You may want to consult your tax advisor or Fidelity. Moving assets from a prior employers plan to your current employers plan Moving assets from a Rollover IRA to your current employers plan Moving assets from a Traditional, SEP, or SIMPLE IRA to your current employers plan

Moving assets from one investment provider to another within the same employers plan D. FIDELITY ACCOUNT YOU ARE MOVING ASSETS INTO Plan Type 401(a) 401(k) 403(b) 457(b) governmental

Select only one plan type and provide the plan number if you know it. If the plan type and plan number you indicate do not agree, we will use the plan type.
Plan Number (if known)

E. INVESTMENT INSTRUCTIONS Tell us how you want your assets from this transaction to be invested. Invest in your current investment elections We will apply the allocation currently on file with Fidelity that applies to the type of money and/or transaction involved. Create a custom investment mix Indicate your fund choice(s)
and percentage(s) below. This mix will apply to this transaction only.

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4. Your Authorization
All account owners/participants By signing below, you: Direct the investment provider identified on this form in Section 2 to liquidate the designated amount of the account(s) listed on this form, and to release the proceeds to your account under your employers plan, except to the extent your current employer or any of your former employers prohibit such release. In the event of such prohibition, you direct said investment provider to retain the portion of your account(s) that cannot be released in a separate account or contract and to release the remainder. Agree to the terms and conditions stated in this form. Certify that you are requesting a vendor or contract exchange, in-plan transfer, or rollover of your retirement plan assets in accordance with applicable IRS and plan rules. Certify under the penalties of perjury that your Social Security or U.S. Tax Identification number on this form is correct. Certify that the information provided on this form is true, accurate, and complete to the best of your knowledge. Acknowledge that you have read the prospectus for any mutual fund in which you invest, and you agree to the terms. Acknowledge that the following assets will be invested according to the investment choices in place for your account on the day the assets arrive: - any residual balances that are received by Fidelity more than 30 days after receipt of initial payment - any installment payments after the first installment payment - all assets being moved, if you are enrolled in Fidelity Retirement PlanManager (FRPM) Acknowledge that the following assets will be invested in the default investment option specified in the agreement currently in place with Fidelity for your plan: - any assets from a contribution source for which no allocation has been selected - any assets allocated to an invalid or illegible fund choice - all assets being moved, if your allocation choices do not total 100% For 403(b)-to-403(b) vendor or contract exchanges In the addition to the terms above, by signing below, you: Acknowledge that any balances you are exchanging from a 403(b)(1) annuity into a 403(b)(7) custodial account may be subject to more restrictive withdrawal provisions. Acknowledge that if you request an exchange from a contribution source not allowed by your plan, the disallowed amount will be returned to the investment provider identified in Section 2. Direct Fidelity to treat all monies as pretax contributions made after 12/31/88 unless the investment provider identified in Section 2 provides Fidelity with account balances as of 12/31/88 and post-1988 salary reduction contributions. Direct Fidelity to treat the entire balances as subject to minimum distribution requirements unless the investment provider identified in Section 2 provides Fidelity with account balances as of 12/31/86. Direct Fidelity to allocate the entire balance to the most restrictive source in the current employers plan unless the investment provider identified in Section 2 provides Fidelity with the sources of the exchanged amount under the previous plan.
Your Signature: Date mm / dd / yyyy

X
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5. Current Employer Authorization

To find out if this signature is required in your case, contact Fidelity.
Current Employer Signature: Date mm / dd / yyyy

X
Company Name Title

Questions? Contact Fidelity at 1-800-890-4015 (for the deaf and hard of hearing, 1-800-610-4015), 8:30am to 8:30pm Eastern Time Monday through Friday (except for New York Stock Exchange holidays).

Form completed?
1. Be sure all information is provided (including SSN or TIN) and you have signed the form. 2. Obtain a current employer signature in Section 5 if one is required. 3. Make a copy of the most recent statement from each account you want to move money out of. 4. If you are sending a check, please write your name and plan number on the check. 5. Send the form and the statement copy to the appropriate address.

Regular Mail:

Fidelity Investments PO Box 770002 Cincinnati, OH 45277-0090

Overnight Delivery:

Fidelity Investments 100 Crosby Parkway, KC1E Covington, KY 41015

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505015.4.0

Transfer/Rollover/Exchange Form

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